Here are 11 small and not-so-small things our panel of experts say you can do to improve your facility's anesthesia efficiency.
Talking to each of your patients the day before their procedures might be time-consuming, but if you can manage the task, it's well worth it, says Jay Horowitz, CRNA, the president of Quality Anesthesia Care Corp. in Sarasota, Fla.
"When I'm working in a cosmetic/plastic surgery facility, I might only have a couple patients, so it's not a hardship," he says. "When I'm working in an endoscopy or ophthalmology center, my staff and I will make an attempt to talk to every patient beforehand - but it's not always possible."
In addition to covering the general pre-admission questions (such as age, height, weight, medical history, medications and allergies), Mr. Horowitz runs through in detail what he'll do, what the patient can expect and reinforces any NPO requirements.
"Talking to patients the night before makes the whole morning go a lot faster," says Mr. Horowitz. "And I can keep the conversation lighter, which helps decrease anxiety."
Advance paperwork Make it worth your staff's while to ensure paperwork is reviewed in plenty of lead time, says Alan P. Marco, MD, MMM, the chairman of and an associate professor at the department of anesthesiology at the Medic-al College of Ohio at Toledo. "Build a system that compensates people for collecting the data and sending it to the anesthesia provider," says Dr. Marco. "You'll be able to show the cost savings in decreased delays and cancellations."
If you're doing a lot of upper- and lower-extremity procedures, such as carpal tunnel and shoulder surgeries and bunionectomies, you might want to examine nerve blocks as a way to enhance efficiency.
The catch: Your anesthesia provider must be well-trained in the technique. (If he's not, and you want to do blocks, help him find a program or course in the region.)
Marc Reichel, MD, the staff anesthesiologist at the Surgery Center of Beaufort in Beaufort, Ill., says his block patients go home quicker, "need little to no post-op pain medication and have decreased use of their prescribed pain meds. And with less used of prescribed opioids, we've seen a decrease in PONV and sedation - which has led to more satisfied patients."
Kerry Gossett, BS, CRNA, of Anesthesia Management Solutions, echoes these sentiments: "We cover a clinic that does a lot of hemorrhoidectomies and we do a lot of blocks; the result has been terrific turnover."
To make blocks worth the extra time they take pre-op, schedule cases accordingly and use a separate block room wisely, says Dr. Marco.
"[A block room] is generally a good idea," he says. "It's handy in the morning, when the ORs are full, but if the OR is empty, it doesn't make sense because it necessitates two moves of the patient. Don't let the OR sit empty while you're in the block room; do the block in the OR."
Preventing PONV is a delicate balance of cost and comfort. Here's one protocol1 to follow:
- Take into account the patient risk factors:
? ?- female,
? ?- history of motion sickness,
? ?- history of PONV,
? ?- non-smoker and
? ?- post-op use of narcotics.
- Take into account the procedure risk factors:
? ?- laparoscopy or laparotomy,
? ?- ENT surgery and
? ?- strabismus surgery.
- Take into account they type of anesthetic:
? ?- opiod analgesics,
? ?- nitrous oxide and
? ?- volatile inhalational anesthetics.
Count each as one point to determine the prophylaxis:
- Mild risk (1-2). Dexa-methasone (less than 8mg), scopolamine, serotonin antagonist (such as ondansetron or granisetron) or droperidol.
- Moderate risk (3-4). Serotonin antagonist with dexamethasone, or serotonin antagonist with droperidol.
- High risk (more than 4). A combination of agents from moderate-risk list, total IV propofol anesthesia and high O2 concentration (at least 80 percent) intraop.
"Customize it," says Linda Chitwood, CRNA, MS, of Senatobia, Miss. "Don't routinely administer expensive anti-emetics; that just costs money. Give it to patients who need it."
A propofol-based regimen for minimally invasive surgeries reduces use of opioids and PONV medication. Barry L. Friedberg, MD, a Corona Del Mar, Calif.-based anesthesiologist, titrates propofol and ketamine for induction and maintenance, and uses a bispectral index, NIBP, EKG and pulse oximetry monitors. The result, say Dr. Friedberg and others, is happier, faster-recovering patients.
"Using PK, I have zero PONV," says Mr. Horowitz. "Even when I do general, I run a propofol drip to avoid inhalational agents. It's expensive, but you have to balance that against recovery room staffing and anti-emetics."
The face cost of propofol may seem prohibitive but, says Ms. Chitwood, "propofol costs $4 to $8 an hour more than an inhalational agent. But an anti-emetic costs about $25 a bottle."
When anesthesia providers and surgeons anesthetize patients together, the result is quicker, more pleasant recoveries. Take, for example, a breast biopsy, says Dr. Dorin. The anesthesia provider administers sedatives, the surgeon administers local to numb the site. The result: Earlier emergence.
This method is also less likely to leave patients nauseous, says Dr. Friedberg, because they breathe on their own.
Local might slow the pre-op process if you spend extra time explaining to the patient that, he'll feel something yet be comfortable, says Ms. Chitwood.
But if the surgeon is comfortable with the technique - and you're comfortable with him - it can be worth it.
"You just have to be very selective with the patient, the procedure and the surgeon," says Mr. Gossett.
Supralaryngeal airway devices
Dr. Dorin recommends a laryngeal mask airway (LMA) on all patients for whom it's clinically appropriate and says he uses an LMA in about 80 percent of his cases. Here are his reasons:
- An LMA keeps the patient breathing spontaneously throughout the case.
- You don't administer muscle relaxant and reversal.
- An LMA does not go through the vocal cords, so it's less irritating to the throat.
"Unless the patient has to be prone or has a full stomach or the insufflation would preclude using an LMA, I use one," says Dr. Dorin. "You can have a patient deep but breathing, so they wake up quicker. It's really streamlined my practice."
Mr. Gossett notes LMAs won't increase costs over endotracheal tubes if you buy reusables.
Narcotics are well-known for making patients nauseous and weak; all but cutting them out can mean less PONV and shorter PACU stays.
"You don't really need opiates and benzodiazepines," says Dr. Dorin. "Not that I don't need or use narcotics sometimes, but 95 percent of the time I don't give them. I wait for recovery to see if they need them."
Allan Goldman, MD, of Seattle, Wash., suggests oral Vioxx because it doesn't have an anti-platelet effect.
"You can start patients on prescription pain killers the night before," says Ms. Chit-wood. "They're very effective, but usually very expensive - so only do it for patients with good pharmacy insurance."
If surgeons or anesthesia providers are reluctant to incorporate the alternatives to narcotics because it's outside their comfort zones, Mr. Gossett suggests you run a one-month trial on the caveat that, at the trials' end, you'll compare PONV rates and PACU times and go with the drugs with better results.
A recent study indicates it might be possible to replace IV patient-controlled analgesia with fentanyl patches.
The study in the March issue of the Journal of the American Medical Association found fentanyl patches and IV PCA morphine were rated nearly equivalent for pain control during the first 24 hours post-op. About three-fourths of patients reported good or excellent pain control with fentanyl patches (73.7 percent) and IV PCA morphine (76.9 percent).
The patches could also simplify post-op instruction. If more studies have similar results, "that makes post-op pain control cheap and easy to send home," says Mr. Horowitz.
But such use is currently off-label. "For right now, that's not something I would feel comfortable using," says Ms. Chitwood. "But it's something to look at as it develops."
Don't go overboard on patient-discharge rules, says Mr. Horowitz.
One discharge protocol you can follow assigns zero to two points for seven indications of patient recovery: level of consciousness, physical activity, hemodynamic stability, oxygen saturation, post-op pain control, PONV symptoms and respiratory stability. If a patient scores 12 or higher with no zeroes, he's ready for discharge.
If you bill anesthesia care as unsupervised, you avoid potential fraud problems and free up CRNAs and MDs to work separately, says Mr. Horowitz.
Medicare's Tax Equity and Fiscal Responsibility Act (TEFRA) rules cover reimbursement, not standards of care; there is no government requirement that MDAs supervise CRNAs, even if your facility requires it (most states require some for of physician supervision). If anesthesia groups bill the case as supervised by an MDA, they must meet TEFRA's guidelines, which include an MDA's presence for induction and emergence. Non-compliance with the TEFRA rules constitutes fraud and could be punishable with fines and legal action. Reimbursement is the same whether the anesthesia services are billed as supervised or unsupervised, as long as the anesthesia providers have assigned their billing rights to the group or the facility.
More you can do
Anesthesia efficiency means different things to nurses, physicians, anesthesia providers and the facility. To effect true quality improvement, you must implement changes that benefit everyone.
"You have to take a big-picture approach," says Dr. Marco. "Look at multidisciplinary things that can be extended to all facilities, protocols, staffing and pre-op processes to minimize delays and cancellations on the day of surgery."
1. Gan, TJ, et al. Anesthesia and Analgesia. 2003;97:62-71.